Abstract

Pediatric dentists have an important role in the care and maintenance of oral health for children
with Autism Spectrum Disorder (ASD). The primary goals of dental care are to maximize oral health
and function, and to help facilitate understanding of the primary features of ASD with families
and other medical and dental providers. To assist oral health professionals in the understanding
of autism and associated comorbidities, this report reviews the medical presentation of patients
with autism and implications for dentistry. We describe the physiological, behavioral, sensory and
gastrointestinal considerations of ASD, as well as associated medical conditions, pharmacologic and
non pharmacological behavior guidance, and dental considerations for the management of patients
with autism. Optimization of oral health is more likely when providers understand the context of
patients who present with autism and are able to educate families, guiding them toward effective
interventions for health.Keywords: Autism spectrum disorder; Children; Behavioral; Sensory and gastrointestinal
considerations; Pediatric dental and oral health

Introduction

Autism Spectrum Disorder (ASD) is a set of lifelong neurodevelopmental disorders defined by
deficits in social and verbal communication with repetitive and stereotyped behaviors. Onset occurs
during early childhood, with symptoms beginning at six months of age and becoming established
by age two or three years [1]. ASD is characterized by a set of core deficits, including impaired
communication and social interaction, and repetitive stereotyped patterns of behaviors or interests
[2].
ASD is a spectrum of symptoms on a continuum of severity ranging from mild to severe. This
spectrum includes Autistic disorder, Asperger syndrome, and Pervasive Developmental disorder
not otherwise specified. Guidelines for diagnosing ASD are found in the Diagnostic and Statistical
Manual of Mental Disorders 5 (DSM-5). DSM-5 states diagnostic criteria within two domains:
1. “Persistent deficits in reciprocal social communication/interaction” and
2. “Restricted, repetitive patterns of behavior, interests, or activities” [3].
The severity of the diagnosis is further detailed into three levels:
1. Requiring support,
2. Requiring substantial support,
3. Requiring very substantial support.
Additional diagnoses are made if a patient presents with or without intellectual impairment,
language impairment, or any other known medical, neurodevelopmental or behavioral disorder
[3]. The DSM-5 reclassified Asperger’s disorder as a high-functioning form of autism due to those diagnosed having average to above average intelligence while sharing
clinical features with autism [4]. In 2016, the Centers for Disease
Control and Prevention reported the prevalence of autism to be 1
in every 68 births in the United States, with 4 times as many males
affected as females [4].

Figure 1

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Figure 1
Visual Aid example for tooth brushing.

Intellect and Abstract Reasoning

Epidemiological studies have reported below-average intelligence
scores (IQ) in approximately three-quarters of individuals with
autism. Two-thirds of these individuals demonstrate an IQ of less
than 70, placing them in the range defined as having intellectual
disability [5]. Children with ASD demonstrated poorer performance
relative to typically-developing individuals in response inhibition,
vigilance, working memory, flexibility, and shifting of tasks [6].
Nation et al. [7] reported 65% of subjects with autism demonstrated
reading comprehension substantially below (>1 standard deviation)
population norms, and about one-third exhibited very severe reading
comprehension impairments.
Dawson et al. [8] suggested that some individuals with high
functioning autism had superior abstract reasoning ability, abstract
thinking, pattern identification, problem solving, and discernment of
relationships when compared to typical individuals. Of the individuals
assessed by Hayashi et al. [9], participants with high-functioning
autism performed better than typically developing individuals when
tested for abstract reasoning ability and fluid intelligence. This level
of reasoning may not persist, as multiple studies report that children
with ASD experience decreased executive functioning with aging
[10].

Physical Movement and Motor Deficits

Dyspraxia, a brain-based condition that negatively affects
planning and coordination of physical movement has been reported
consistently in children with autism. This condition may contribute to
impaired motor control and imitation of skilled gestures, ultimately
affecting an individual’s posture, balance, speed, coordination,
reaction time and grip strength [11]. Difficulty performing skilled
motor gestures is one commonly reported trait in children with
autism [12]. Impaired performance of skilled gestures has been
suggested as contributory to abnormal social development and
communication [11].
Motor deficits associated with autism can be identified in infancy,
and may be associated with abnormalities in perception of biological
motion as well as the favoring of proprioception over visual feedback
when learning motor skills [13]. Generalized praxis deficits noted in
high functioning children with autism are not limited to imitation
gestures, and may be associated with anomalies in the frontal/
parietal-subcortical circuits involved in learning and execution of
sensory representations of movement [12]. Serdaravic et al. [14]
investigated the association of infant neuromotor development with
traits of autism, and demonstrated a modest association between
overall neuromotor delay early in life and signs of autism in school age
children. Neuromotor functioning during infancy is a valuable gauge
of central nervous system development. Therefore, motor problems,
especially hypotonia, detected in early infancy are a valuable part of
screening for ASD [14].

Language and Verbal Communication Skills
Deficits

Language abilities are highly variable in individuals with autism
[15]. Joseph et al. [5] described uneven cognitive development in
children with autism, with verbal skills more affected than nonverbal
skills. When comparing subjects with similar IQ, individuals with
autism often demonstrated more impaired language skills than
typically-developing individuals [15]. Communication impairments
can affect both expressive and receptive language abilities. 33-50% of
children with ASD never develop functional speech, and those who
have verbal skills tend to have delays in language acquisition [16].
As early as the first year of life, before the emergence of spoken
language, signs of social and communication disruption may be
detected in children with autism. By 18-24 months of age, five core
social communication deficits are detectable: “gaze shifts, gaze
point follow, rate of communication, acting for joint attention, and
number of gestures” [17,18]. By the second and third years of life,
communication is impaired by reduced frequency and diversity of
babbling, gestures, and use of consonants in syllables, in addition to
the use of unusual words or word combinations [19]. Wetherby et
al.[20] described a screening checklist for healthcare providers as best
identifying children under age 24 months with autism in the areas of
lack of conventional play with a variety of toys, failure to vocalize with
consonants, lack of pointing, and lack of response to contextual cues.

Brain Development and Neural Processing
in Autism Spectrum Disorder

Autism is characterized by the comprehensive dysfunction of
the association cortex, which comprises most of the brain’s cerebral
surface and is chiefly responsible for complex processing linking
sensory cortices and behavior [21]. This region’s dysfunction results in irregularities in multifaceted behavior, language, and cognition
[22]. Recent craniofacial studies of individuals with autism noted
the common finding of increased head circumferences. Studies
of head circumference in autism established a group mean head
circumference at the 60th through 70th percentile in relation to typical
norms, which was disproportionate in consideration of height and
weight [23]. An increase in total brain volume has been confirmed
using magnetic resonance imaging and was recognized in children
starting between the ages of 2-4 years [24].
ASD has established associations with increased seizure frequency,
epilepsy, and sensory hyper-reactivity. Shifts in cortical excitability
affect sensory function due to the dependence on the dynamic accuracy
of the excitatory and inhibitory balance to distinguish neural signals
[25,26]. Evidence proposes that the pathway involved in cortical
excitability is associated with impairments of specific aspects of
inhibitory Gamma-Aminobutyric Acid (GABA) neurotransmission.
GABA is the primary inhibitory neurotransmitter synthesized from
the excitatory neurotransmitter glutamate [27].

Sensory Abnormalities and Pain Tolerance

Somatic sensory perception and emotional reaction affect pain
sensitivity or tolerance. Abnormal touch sensitivity, proprioception,
and painful stimuli are characteristics that have been described in
individuals with ASD [28]. Using well-controlled stimulations, it has
been suggested that individuals with ASD are hyposensitive to pain.
Riquelme et al.[29] assessed somatosensory function in the face and
hands, as well as upper limb motor function in children with ASD, and
demonstrated lower pain threshold and higher tactile sensitivity at
the face and hand dorsum compared to typically-developing children.
Furthermore, children with ASD had a decreased capability in object
manipulation and expressed poorer upper limb proprioception. The
high pain sensitivity may be attributed to an abnormality in processing
of the affective component of pain mediated by C-fibers. This study
demonstrated the impairment of tactile and pain thresholds in
children with ASD, supporting the notion that abnormal processing
of the affective-motivational dimension of touch may be contributory
[29].

Genetic Basis of Autism Spectrum Disorder

Numerous familial studies over several decades demonstrate
the heritability of autism spectrum disorder. Twin studies provide
estimates of the genetic contribution to ASD, exhibiting 76-88%
concordance for ASD in monozygotic twins and 0-31% in dizygotic
twins [30]. The recurrence risk of ASD in siblings is approximately
20% [31]. ASD shows great etiological and clinical heterogeneity,
complicating the determination of a genetic basis of the disorder
[32]. Symptoms present as behavioral manifestations of numerous
interacting genomic imbalances, mutations and environmental
factors [33]. Genetic variants resulting from Copy Number Variants
(CNVs) and Single Nucleotide Polymorphisms (SNPs) act additively
and are present in approximately 10% of individuals with ASD
[30,31]. However, there is no single identified mutation that accounts
for over 1% of ASD cases, leaving the fundamental genetic factors
underlying the spectrum of autism phenotypes incompletely defined
[31].
Structural variations in chromosomes are implicated in ASD, with
linkage on chromosomes 5, X, and 19, and minor evidence for linkage
on chromosomes 2, 3, 4, 8, 10, 11, 12, 15, 16, 18, and 20 [33,34]. ASD
is 4-8 times more common in males than females, emphasizing the
significance of X-linked inheritance [30]. Polymorphisms in the X
chromosome are observed to result in intellectual disability due to
the location of various genes that express neuronal function on the X
chromosome [31]. Impairments in language and social cognition are
observed with several of these mutations [32].

Table 1: Summary of strategies for improving the dental environment for patients
with autism [49,50,52].

Gastrointestinal symptoms and disorders are among the
most commonly reported medical conditions associated with
autism spectrum disorder. However, gastrointestinal disorders
can be challenging to recognize due to communication barriers
that exist for many patients diagnosed with ASD. Symptoms that
traditionally present include constipation, Gastroesophageal Reflux
Disease (GERD), diarrhea, and vomiting. Kang et al. [35] evaluated
gastrointestinal dysfunction in a cohort of 164 children with ASD.
Forty nine percent of the children with ASD exhibited chronic
gastrointestinal complaints, including diarrhea, constipation,
bloating, gassiness, vomiting, and GERD [35]. These commonly
experienced gastrointestinal symptoms often cause pain and
discomfort, and may be linked to unusual eating and sleeping habits,
anxiety, and regression of ASD symptoms [36].

Potential Microbial Causes of
Gastrointestinal (GI) Symptoms

The gut and brain have signaling pathways, which affect exchange
of metabolites, influence the immune system, and control gene
function in an individual [37]. “Cross talk” between the gut and brain
may occur through a direct connection, in which the lamina propria of
GI endothelial cells is triggered to release signaling molecules into the
GI tract, or through an indirect link, by changing motility, secretion,
and permeability in the intestine. This gut-brain communication
is influenced by the individual’s unique enteric microbiome [37].
Children with ASD often have an altered gut microbiota [38,39].
Strati et al. [38] described a decrease in the abundance of the genus
Alistipes, Bilophila, Dialister, Parabacteroides, and Veillonella in
individuals with ASD. However, some microorganisms including
Collinsella, Corynebacterium, Dorea, and Lactobacillus were
significantly increased compared to individuals without ASD. This
study identified an association between constipation and different
bacterial patterns of the gut, and concluded that the constipation
experienced by many individuals with ASD could be attributed to
these microbial differences.

Microbiota transplant has been proposed to be a promising
therapy for individuals with ASD. Current data suggests that shifting
the gut microbiota to a healthy state can reduce the gastrointestinal symptoms associated with ASD. Because these symptoms not only
cause pain and discomfort, but include behavioral symptoms as well,
altering the microbiota in individuals with ASD may potentially
affect eating and sleeping habits, anxiety, and symptom regression
[36, 40]. Efforts to change gut microbiota include the addition of
probiotics and/or prebiotics to the diet, or fecal matter transplants.
Shigwedha et al. [41] suggested that adequate intake of probiotics or
probiotical cell fragments plus commensal microbiota could facilitate
the smooth exchange of metabolites with the host, influence the host
metabolism and immune system, and affect host gene function. Using
fecal microbiota transplant (FMT), Kang et al. [39] repopulated the
standardized gut bacteria within a clinical cohort of children with
ASD. After FMT, the microbial profile shifted towards that of agematched
healthy control subjects. The shift in microbial populations,
as well as improvements in behavioral and gastrointestinal symptoms,
lasted for an 8-week period post-treatment.

Recent meta-analysis assessed the oral health status of children
with ASD compared to typically-developing individuals. The
systematic review concluded that considerably higher prevalence of
dental caries and periodontal diseases occurs in patients with ASD
[42]. However, other studies have reported no differences in caries
prevalence between children exhibiting autistic or typical behavioral
tendencies [43]. Regardless, children with autism are noted to
have poorer oral hygiene, modified dietary behaviors, and lower
compliance in oral health maintenance [42,43].
While all people with teeth are susceptible to caries development,
higher risk exists for patients with autism due to specific behaviors.
Adolescents with autism may display eating habits of pouching a
food bolus between molars and the cheek as a result of lack of tongue
coordination. The location of food pouching is often along the
posterior segments of the jaws, affecting risk for caries development
in these areas [44]. Caries risk is also affected by difficulty in
brushing and flossing to maintain oral hygiene, as children with ASD
experience increased sensitivities and oral aversions [45]. Children
with ASD often exhibit strong preferences for starchy and processed
food over fruits and vegetables [46,47]. Another manifestation in
some individuals with ASD is pica eating disorder, the tendency to
mouth or swallow inedible or non-nutritive substances that are not
characterized as food [48]. This behavior may lead to multiple dental
complications, such as abrasion, tooth fracture, staining, periodontal
problems, and poor oral hygiene.

Autism and Dentistry Practices

Sensitivities and sensory processing alterations can cause
significant challenges in the dental environment, prompting a “fight
or flight” response to overwhelming stimuli [49]. Approximately
50% of children with ASD have been reported to possess oral
aversion or defensiveness. The dental clinic itself has many anxietyproducing
stimuli including bright lights, loud noises, and materials
of unfamiliar textures, smells, and tastes. Multiple operatory units in
the same room can cause confusion and increased disturbance due to
noise and presence of people coming and going [50].
Stein et al. [51] found that significantly more parents of children
with ASD, compared to parents of typical children, reported that their
child was afraid of, disliked, or complained about: dental drilling,
bright lights, loud sounds, having someone put instruments in his or
her mouth, leaning back in the dental chair, and smells of the dental
office. Parents of children with ASD reported significantly more
difficulty with three or more of these sensory variables compared
to of parents of typical children. Furthermore, parents of children
with ASD were more likely to report the use of restraint for routine
cleaning of teeth, as well as general anesthesia, sedation, or other
drugs for dental prophylaxis [51].
Sensory aversions may result in a dislike for the foaming or flavor
of toothpaste and the feeling of the toothbrush, complicating attempts
at plaque removal. Alternatives such as toothbrushes of different
texture or design, electric toothbrushes, or a washcloth may improve
patient acceptance to hygiene aids [50]. Patients may find a compatible
dentifrice by trying different flavors and brands of toothpaste, or
consider brushing the teeth with fluoridated mouthwash, as this
produces less foaming and may be milder in flavor.

Access to Care

Finding a dental home may also be more difficult for individuals
with autism. Dentists accessible to the child may not be qualified or
appropriately trained to manage patients with autism or associated
comorbidities. Significant behavioral tendencies among patients with
autism may also be a factor in locating a dentist equipped to welcome
patients with special healthcare needs. In order to find a dental home,
many families of children with autism may be forced to travel long
distances or seek care in a dental educational institution [49,50].
Stein et al. [51] reported higher incidence of parents having difficulty
locating a dentist to provide care to their child with ASD, or having
been refused treatment by a dentist. Parents cited most frequent
reasons for refusal of services as inadequate training of the dentist for
Special Healthcare Needs (SHCN) patients and the child’s behavior
problems.

Behavioral Approaches

Patients with ASD often present with challenging behaviors
including non-compliance to directions, hyperactivity, sensory
hypersensitivity, combativeness, and self-injurious behavior.
Behaviors may be the outcome of a patient’s anxiety, and range from
emotional outbursts to destruction of objects to harming of others
[52].
Non-pharmacologic methods of behavior guidance use positive
interactions and cultivating relationships between the patient and the
dental team, which may be difficult for children with ASD who exhibit
impaired social communication. Traditional non-pharmacologic
behavior guidance techniques include “positive reinforcement, Tell-
Show-Do (TSD), distraction methods, non-verbal communication,
and voice control”. Patients with ASD who have expressive and
receptive language deficits may not be as amenable to these types of
guidance [49].
Visual pedagogy may be more effective for children with
autism who respond well to pictures than to words. Books, color
photographs, stories, and video modeling can be helpful adjuncts to
more traditional guidance techniques. Visual tools such as a visual
task strip or story-board depicting a sequence of events (Table 1)
and social stories about dental visits, as well as other life skills, are
available on the Internet from variety of sources [49,52-54].
In-depth knowledge and understanding of basic behavior
patterns is important to successfully manage children with ASD
in the dental setting. Most significantly, dental providers must remember that patients with autism exhibit a broad variety of ability,
performance, and intelligence levels. A tailored approach unique to
the characteristics of each child is of utmost importance [50].
The Centers for Disease Control (CDC) and National Research
Council (NRC) recognize the importance of early diagnosis and
treatment for patients with ASD, and support education focusing
on the development of motor skills, social and language skills, and
behaviors considered appropriate. Educational intervention therapy
is indicated as soon as ASD is suspected, and should be provided a
minimum of 25 hours per week [49]. Education for individuals with
ASD includes combinations of Applied Behavior Analysis (ABA),
structured teaching, speech and language therapy, learning of social
skills, occupational therapy, and sensory integration therapy. ABA is
well supported as an efficacious intervention for patients with ASD,
and ABA-based therapies are generally recognized as some of the most
effective in improving behaviors and life skills. These therapies strive
to reinforce desired behaviors and modify undesirable behaviors and/
or responses, recognizing the child’s behavior as it relates to his or her
environment. ABA methods are often used in educational programs
to provide life skills to patients with ASD, and can be modified to the
dental setting as well [49].

Systematic Desensitization

Systematic Desensitization is a technique that can successfully
modify anxiety behavior in the dental setting. Gradual exposure over
time to anxiety-producing components of the dental environment
allows patients to receive dental care more comfortably. A child is
slowly and repeatedly exposed to the dental environment with the
objective of gaining trust and enhancing adaptation [49]. Cooperation
is encouraged with the use of positive reinforcement and practicing
desired behaviors both in the dental office and in an external mock
environment. Use of a positive reinforce (such as a sticker or small
prize) in combination with praise to encourage desired behaviors
can result in the child’s cooperation for dental examinations and
prophylaxis [52]. Utilizing systematic desensitization in the dental
office may require visits as long as 2 hours, with 10-12 visits to
achieve the desired result. Desensitization has a high success rate, but
the extrapolation of results may be limited when the desensitization
process has taken place in a specific environment and with a specific
provider. The time required for this behavior training is often
prohibitive in the dental community [49]. Practicing in a mock
environment such as the home or with the child’s therapist may
facilitate the use of desensitization to achieve improved behaviors in
the dental office [52].
Orellana and colleagues [55] have described applications of the
TEACCH model (Treatment and Education of Autistic and related
Communication-Handicapped Children) to the dental environment.
TEACCH is “a professional training program and a clinical service
for persons with ASD and their families throughout the whole lifespan”.
Structured teaching is based on the neuropsychological
profile of people with ASD, and is reliant on the temporal and spatial
organization of visual information [56]. Orellana’s group applied
the TEACCH model to two groups, child and adult, with the goal of
improving acceptance of dental care in the conventional clinic setting.
Techniques used were:
• Successive Approaches of desired behaviors.
• Tell-Show-Feel-Do, a modification of the common
Tell-show-do behavioral guidance technique to include feeling of
sensations or instruments prior to clinical use.
• Visual pedagogy, wherein photographs, pictographs, and
real objects are associated with short simple sentences. A set of 20
photographic cards (depicting the room, instruments, light, etc.) was
used for each subject describing a dental exam experience.
• In Vivo modeling, wherein a live person demonstrated
desired behaviors.
• Audio-Visual modeling, showing a film of an in vivo model.
• Behavioral trials sequentially practicing ten steps of a
mouth examination.
• Auto-Modeling, wherein photos of the subjects were
taken during the course of the appointment and then reviewed later
emphasizing the positive behaviors. Subjects were encouraged to
practice these actions.
Orellana’s group reported an improvement in Frankl behavior
scores and increase in receptiveness to dental care and the dental
environment after five 20-minute sessions occurring over a period of
3 weeks. After the 5 sessions, over 90% tolerated intraoral examination
with both mirror and probe. By the end of the five sessions, 81.6% of
children and 100% of adults had a Frankl score of 3 or 4. The authors
noted that the amount of behavioral improvement was unrelated
to the level of cognitive impairment of the subject [55]. This study
demonstrated remarkable improvements in subject compliance, and
offers examples of how applied behavior analysis may be targeted for
the dental office.Advanced behavior guidance techniques
Impairments in social skills may decrease the effectiveness of
desensitization and ABA-based therapies, or require longer periods
of time to see positive results. For patients with extreme aversions and
impaired social skills, or for patients with active dental disease at risk
of pain and infection, the modalities of General Anesthesia (GA) or
Protective Stabilization (PS) may be required initially to reduce risks
of morbidity in an urgent situation [49]. PS may be required when
an urgent diagnosis or treatment is required, or for patient and staff
safety when uncontrolled movements occur. In some cases, PS may
be calming to a child with autism due to the pressure produced with
application, however care must be taken to prevent injury for patients
who have unanticipated reactions to the stabilization. When utilizing
PS, adherence to standard guidelines must be observed [57].
Use of sedation may be helpful in some cases; however
practitioners must rule out comorbidities and medication use
that contraindicate procedural sedation and observe established
guidelines for case selection and monitoring [58,59]. Nitrous Oxide
(N2O) used as a behavior guidance tool has mixed support in the
literature. N2O anxiolysis may be helpful for patients with mild
behavior concerns, and is possibly more effective when combined
with other behavior guidance techniques [59]. Some parents or
caregivers may object to the use of N2O due to concerns about
potential Methylene Tetrahydrofolate Reductase (MTHFR) gene
mutations. MTHFR related gene mutations and folate metabolism
dysregulation have been reported in patients with autism. However,
there is no evidence of mortality associated with use of nitrous oxide
as typically administered in the dental setting [52]. Deaths associated
with MTHFR deficiency have only been reported in cases with
prolonged exposure to high levels of nitrous oxide under general anesthesia, and risk is higher for patients that are homozygous for
the genetic mutation [60,61]. Providers should help parents make
informed decisions about the use of N2O by discussing risks and
benefits and other possible treatment options and by consulting with
practitioners regarding folate metabolism anomalies and MTHFR
genetic mutations [52].
General Anesthesia (GA) is a frequent modality for patients
with autism, due to factors such as extensive treatment needs,
patient safety, dental provider and team safety, and uncooperative
behavior [52]. Approximately 40% of patients with autism require
GA to safely administer dental intervention [50]. Although GA
is generally considered to be safe, patients with autism have been
reported to experience adverse events including significant disruptive
behaviors, postoperative vomiting, postoperative seizures, and
patient manipulation of surgical sites causing bleeding. Challenging
perioperative behaviors may necessitate the need for pre-medication
as well as additional staff or stabilization [52].

Dental Appointment Considerations

Parents may have their own preferences about restorative
materials, fluoride-containing products, behavior management
strategies, personnel, or location inside the office for dental
examination. A family centered approach is crucial in building trust
with patients and parents. Collaborative planning of the patient’s care
can result in more effective long-term oral health maintenance [52].
Some caregivers or parents may object to dental products
containing fluoride or restorative materials containing mercury
(amalgam) or bisphenol-A (resin composites) due to concerns
about toxicity. The reasons for refusal of these products should be
carefully discussed with the parents, along with caries risk assessment
and exploration of alternatives. Discussing options with caregivers
in a detailed and family centered manner will aid in making
treatment-planning decisions [52]. Alternatives to fluoride could
include chlorhexidine or xylitol as topical chemotherapeutic agents.
Alternatives to amalgam and composite could include glass ionomer
products and stainless steel crowns.
Patients with ASD can often tolerate procedures better when
the events are predictable and expected. Helping families to prepare
ahead of time will make dental appointments go more smoothly.
Caregivers are valuable partners in this endeavor, as they know the
child’s behavior and communication styles well and can provide
information about what approaches have worked well for the patient
in other environments. A pre-visit questionnaire for caregivers, such
as the one published by Nelson et al. [49], includes information
about the child’s behaviors, sensory sensitivities, recommended
time of day for procedures, time required, and other alterations in
the environment to improve patient comfort. Sensory-Adapted
Dental Environments (SADE) reduces the presence of potentially
distressing stimuli, for example by removing fluorescent lighting and
by playing relaxing rhythmic music. Dark glasses and noise-canceling
headphones or ear-muffs may also help to avoid overstimulation in
the dental office [49,50].
Communication from the dental team in a calm voice using
short, simple sentences may help reduce patient anxiety as well as
clarify expectations. Avoid symbolic language or figures of speech,
as patients with ASD are likely to interpret language literally. When
touching a patient, use firm pressure rather than light touch, and
avoid unnecessary contact. Use of massage by the caregiver or dental
provider and coping objects (such as a toy or tablet/computer) may
improve patient response. Some patients with ASD are soothed by
pressure, and may benefit from use of a weighted blanket (such as the
x-ray apron) or swaddling with blankets/pillows [49](Table 2).

Conclusion

Autism Spectrum Disorders encompass a wide range of
symptoms, presentations, abilities, and challenges. The genetic,
neurologic, sensory, and gastrointestinal considerations associated
with ASD affect daily life, oral health, and the ability to receive dental
care. The psychological well-being of parents and caregivers are often
influenced by the behavior of their children. Nearly two-thirds of
parents with a child with ASD report difficulty with daily oral care and
significantly more need for physical assistance in performing daily
tasks. Raising a child with ASD necessitates adaptation to the child’s
routines and can pose challenges for engagement in the educational
and health care systems. Furthermore, limited availability of resources
to support families with a child with ASD can complicate access to
care. Thus, a dental visit can represent a major source of stress for
all individuals, including the child, caregiver, and provider. Dental
healthcare professionals with a thorough understanding of autism
spectrum disorder and associated conditions will be better prepared
to provide a welcoming environment for patients with autism and
their caregivers. Patience, collaboration, and an individualized
approach are crucial in providing oral health care in an effective, safe,
and positive environment for this growing sector of the population.